What is the initial management for a patient presenting with ascites?

Initial Management of Ascites

The initial management of ascites should consist of sodium restriction (5-6.5g salt/day) and oral diuretics, starting with spironolactone monotherapy 100mg daily for first presentation of moderate ascites, with diagnostic paracentesis performed in all patients with new-onset ascites. 1

Diagnostic Approach

1. Diagnostic paracentesis is essential for all patients with new-onset ascites to:

   • Determine serum-ascites albumin gradient (SAAG)
   • Obtain cell count and differential
   • Culture fluid to rule out spontaneous bacterial peritonitis (SBP) 1
   • Ultrasound guidance should be considered when available to reduce adverse events

2. Laboratory evaluation should include:

   • Liver function tests
   • Renal function tests
   • Serum electrolytes
   • Complete blood count

Treatment Algorithm

First-Line Treatment

1. Dietary sodium restriction:

   • Restrict sodium intake to 5-6.5g salt/day (87-113 mmol/day)
   • Provide nutritional counseling on sodium content in diet 1

2. Diuretic therapy:

   • Initial approach: Start with spironolactone monotherapy 100mg daily 1
   • Mechanism: Spironolactone acts as an aldosterone antagonist, competing with aldosterone for receptor sites in the distal convoluted renal tubule, causing increased sodium and water excretion while retaining potassium 2
   • Administration: Give as a single morning dose to maximize compliance 1
   • Titration: Increase dose as needed up to maximum 400mg daily 1

3. For recurrent or severe ascites:

   • Add furosemide 40mg daily (can be titrated up to 160mg daily) 1
   • Combination therapy with spironolactone (100-400mg) and furosemide (40-160mg) is recommended 1

Management of Tense Ascites

• Perform therapeutic paracentesis for rapid symptom relief
• Administer albumin for large-volume paracentesis 1
• Consider albumin infusion even for paracentesis <5L in patients with acute-on-chronic liver failure 1

Monitoring and Adjustments

1. Regular monitoring:

   • Serum electrolytes
   • Renal function
   • Weight (recommended weight loss: 300-500g/day in patients without peripheral edema) 3

2. Potential complications to monitor:

   • Hyponatremia
   • Hyperkalemia (particularly with spironolactone)
   • Renal impairment
   • Hepatic encephalopathy

3. Medication adjustments:

   • In patients with hepatic cirrhosis and ascites, therapy should be initiated in the hospital setting 4
   • Sudden alterations of fluid and electrolyte balance may precipitate hepatic coma 4
   • Avoid NSAIDs as they can reduce sodium excretion and convert patients from diuretic-sensitive to diuretic-resistant 1

Management of Refractory Ascites

Refractory ascites is defined as ascites that does not respond to sodium restriction and maximum doses of diuretics, or recurs rapidly after therapeutic paracentesis 1

Options include:

1. Serial therapeutic paracentesis with albumin replacement
2. Transjugular intrahepatic portosystemic shunt (TIPS) in appropriate candidates
3. Liver transplantation evaluation 1

Important Caveats

• About 90% of patients respond well to medical therapy for ascites 3, but approximately 10% develop refractory ascites 5
• Patients with cirrhosis and first onset of ascites have a probability of survival of 85% during the first year and 56% at 5 years without liver transplantation 5
• Spironolactone is more effective than furosemide in the elimination of ascites in cirrhotic patients 6
• In patients with hepatic coma or electrolyte depletion, diuretic therapy should not be initiated until the basic condition is improved 4
• Liver transplantation should be considered as it offers a definitive cure for cirrhosis and its complications 5